To my family, doctors, hospitals, surgeons, medical care providers, and all others concerned with my care:

I,______________________________, being of sound mind and rational thought, willfully and voluntarily make this declaration to be followed if I become incompetent or incapacitated to the extent that I am unable to communicate my wishes, desires and preferences on my own.

This declaration reflects my firm, informed, and settled commitment to refuse life-sustaining medical care and treatment under the circumstances that are indicated below.

This declaration and the following directions are an expression of my legal right to refuse medical care and treatment. I expect and trust the above-mentioned parties to regard themselves as legally and morally bound to act in accordance with my wishes, desires, and preferences. The above-mentioned parties should therefore be free from any legal liabilities for having followed this declaration and the directions that it contains.

Directions

1. I direct my attending physician or primary care physician to withhold or withdraw life-sustaining medical care and treatment that is serving only to prolong the process of my dying if I should be in an incurable or irreversible mental or physical condition with no reasonable medical expectation of recovery.

2. I direct that treatment be limited to measures which are designed to keep me comfortable and to relieve pain, including any pain which might occur from the withholding or withdrawing of life-sustaining medical care or treatment.

3. I direct that if I am in the condition described in item 1, above, it be remembered that I specifically do not want the following forms of medical care and treatment:

   A. _____________________________________
   B. _____________________________________
   C. _____________________________________
   

4. I direct that if I am in the condition described in item 1, above, it be remembered that I specifically do want the following forms of medical care and treatment:

   A. _____________________________________
   B. _____________________________________
   C. _____________________________________
   

5. I direct that if I am in the condition described in item 1, above, and if I also have the condition or conditions of ____________________, that I receive the following medical care and treatment:
   This Living Will Declaration expresses my firm wishes, desires, and preferences and the fact that I may have executed a form specified by the law of the State of _____________________, may not be used a limiting or contradicting this Living Will Declaration, which is an expression of both my common law and constitutional rights.

   I make this Living Will Declaration the _______ day of __________, 20____.

   
   _______________________________________________ Declarant's Signature ________________________________________________
   ________________________________________________
   ________________________________________________ Declarant's Address

   Witness Statements

   I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.

   ________________________________________________ Witnesses' Signature

   ________________________________________________ Witnesses' Printed Name

   ________________________________________________
   ________________________________________________ Witnesses' Address

   I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.

   ________________________________________________ Witnesses' Signature

   ________________________________________________ Witnesses' Printed Name

   ________________________________________________
   ________________________________________________
   ________________________________________________ Witnesses' Address

   Notatization

   STATE OF _______________________, COUNTY OF ___________________

   Subscribed and sworn to before me this ________ day of ________, 20_____.

   _______________________________ Signature of Notary Public

   My commission expires: ________________________________